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While assessing a radial artery catheter, the client complains of numbness and pain
distal to the insertion site. What interventions should the nurse implement? -
Promptly remove the arterial catheter from the radial artery.
A client is admitted with an epidural hematoma that resulted from a skateboarding
accident. To differentiate the vascular source of the intracranial bleeding, which
finding should the nurse monitor? - Rapid onset of decreased level of
consciousness.
When preparing a client for discharge from the hospital following a cystectomy
and a urinary diversion to treat bladder cancer, which instruction is most important
for the nurse to include in the client's discharge teaching plan? - Report any signs
of cloudy urine output.
After repositioning an immobile client, the nurse observes an area of hyperemia.
To assess for blanching, what action should the nurse take? - Apply light pressure
over the area.
The nurse enters a client's room and observes the client's wrist restraint secured as
seen in the picture. What action should the nurse take? - Reposition the restraint tie
onto the bedframe.
A female client with acute respiratory distress syndrome (ARDS) is chemically
paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2.
Which assessment finding warrants immediate intervention by the nurse? -
Diminished left lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or tension
pneumothorax, which required immediate chest tube insertion to re-inflate the
lung.
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